LESSONS LEARNT in an INQUIRY

Inquiries serve as powerful tools for examining incidents and identifying areas of improvement. Understanding the root cause is crucial for preventing similar incidents in the future.

During my Master of Management degree, one significant case study that particularly resonated with me was the 1993 failure of the Information System implementation for the London Ambulance Service (LAS).

In 1992 LAS received some 2,000 and 2,500 calls, transports over 5,000 patients daily and emergency calls accounted for over 60% of the calls. The project was to automate the despatch of ambulances in London. At the time LAS was the largest ambulance service in the world. Automation was implemented on the 26 October 1992 and considered a total failure on 4 November 1992, nine days later.

An inquiry into LAS found the project was managed poorly and the skills, knowledge and competencies of the project manager did not match the complexity of the computerised information system project. There were serious consequences to the failed project. For instance the delays in emergency response times. It was estimated only a few patients died as a result of the failed system. I would like to dispute that but the exact number is unknown.

Most inquiries into organisational fiascos can be consistently traced back to leaders and management. Even though there were a comedy of errors in the LAS project management case study, such as budget blow out and staff sabotage, a contributing factor to the failure of the project was the inadequate training and skilling of users. People, rather than systems, should be at the core of every level of business, community, and government. So, what has LAS inquiry anything to do with a current news story, you ask?

Yesterday Clare Nowland, a 95-year-old Australian woman died after a police officer Tasered her at Yallambee Aged Care Nursing Home. Admittedly the 43kg frail, old resident was holding a steak knife. We suspect the elderly woman's dementia behaviour was challenging for staff in order for the facility to call in the 'big guns'. Senior constable Kristian White, 33, arrived only to Taser the nanogenarian. He is scheduled to appear in court for major offences and possibly a maximum penalty of 10 years in prison. A tragic outcome for both Clare and Senior constable White.

Training and upskilling are often common recommendations in inquiries. They recommend training and upskilling programs to enhance the capabilities of individuals to prevent similar incidents in the future.

I suspect in this case targeted dementia training will be suggested, but why not prior to the incident? Why after the event?

I strongly believe leadership and management in both the Police department and Aged Care facility should be held accountable for the loss of both lives.

Does it take an inquiry to recommend training and upskilling initiatives? Obviously yes.

Quite often leaders and managers do not see the benefits and value of training and upskilling programs, or undervalue the impact on employee performance and organizational success.

So often I hear the excuse of budgetary constraints or other business needs over employee development. Then there's the typical management resistance to change issue, leadership incompetent in change management skills or employees resistance due to fear of the unknown or reluctance to step outside their comfort zones.

"We don't have time!" Another excuse. Training and upskilling does require a slice of time from a busy schedule, but then hey, consider the return on investment (ROI). Ohh yes, how do you measure return on investment, you ask? Who cares, trust training works. Informal evaluation can be just as a powerful tool and formal measurements.

A common avoidance of training and upskilling programs is avoidance itself. Leaders may not see a direct alignment between training and upskilling and the strategic goals of the organisation. This kind of misalignment results in reduced employee development. Is that what organisations want?

Who suffers when leaders and managment of organisations (in this case the Police department representative of all government organisations national wide and Yallambee Lodge, a representative of Aged Care Nursing Homes nation wide. Another atrocity in a developed country.

• May Clare Nowland Rest in Peace (RIP)
• May her family be consoled in knowing there are innocent and decent employees working to wholeheartedly make a difference in the lives of our community. Unfortunately it is not the system that let her down but leaders and management within departments who failed to train an upskill their staff. I pray her passing will not go in vain.
• May community uphold the Charter of Aged Care Rights in the hope they and their loved one are not abused, mistreated, neglected, exploited or harmed.
• May every person living with dementia be met with understanding, tolerance, kindness, warmth and quality care.
• May we unite for the common good of humanity and find our voice to demand training and upskilling in an ever changing world of work. In the worst case, take the lead and foster a culture of continuous learning and development.